Parties involved

Ms A
Consumer

Ms
B
Friend of consumer

Dr
C
Provider/General practitioner

Dr
D
Provider/General practitioner

Ms
E
Registered nurse

Ms
F
Registered nurse

A Medical
Centre
Provider/Employer

Complaint

On 24 January 2005, the Commissioner received a complaint from
Ms A through a Health and Disability consumer advocacy service
trust, about the services provided by Dr C and Dr D. The
issues identified for investigation
were:

Dr C

The appropriateness of the care and treatment provided by Dr C,
General Practitioner, to Ms A in July and October 2004.

Dr D

The appropriateness of the care and treatment provided by Dr D,
General Practitioner, to Ms A in September and October 2004.

A Medical Centre

The appropriateness of the care and treatment provided by a
medical centre in October 2004.

An investigation commenced on 9 May 2005.

Information reviewed

Information from:

Ms A

Ms B

Dr C

Dr D

The General Manager, the medical centre

Ms E

Ms F

Ms A's

medical records from the medical centre

medical records from the District Health Board

Independent expert advice was obtained from Dr Simon
Brokenshire, a general practitioner and accident and medical
practitioner.

Information gathered during investigation

Introduction

Ms A, aged 36, attended a medical centre on four separate
occasions between July and October 2004. The medical centre is an
ACC endorsed level 2 Accident and Medical Clinic, open from 8am
until 9pm, with over 15,000 regular patients. Ms A was seen
twice by her regular general practitioner, Dr C, and twice in an
after-hours capacity by Dr D, a general practitioner and senior
doctor in emergency medicine.

Consultation on 20 July 2004

On 20 July 2004, Ms A presented to Dr C with dysmenorrhoea
(difficult and painful menstruation) and menorrhagia (excessive
uterine bleeding). Ms A had been experiencing these symptoms
for four months.

During the consultation, Ms A was tearful and stated that she
could not "handle [the] pain any more". Dr C noted that Ms A
had had her last cervical smear and an intra-uterine device (IUD)
inserted six years ago. Her follow-up plan included removing
the IUD[1] and carrying out a cervical smear
when Ms A returned in a fortnight's time. Ms A was agreeable
to the plan and an appointment was booked for 5.15pm on 3 August
2004.

Although it is not recorded in her clinical notes, Dr C advised
my Office during the investigation that she did perform an
abdominal examination as part of the consultation. She
recalled that there were no lumps or specific areas of abdominal
tenderness, and that Ms A had normal bowel sounds. She
explained that the consultation did not include a vaginal
examination, and vaginal and cervical swabs were not taken as Ms A
was experiencing heavy vaginal bleeding and refused internal
investigations.

Ms A did not attend the follow-up appointment with Dr C in early
August 2004.

Consultation on 25 September 2004

Ms A next presented to the medical centre two months later at
approximately 7pm on Saturday 25 September 2004 with lower
abdominal pain. She had an initial triage assessment with the
nurse on duty, who recorded Ms A's temperature as
37.7oC. While Ms A's vaginal bleeding had ceased,
the nurse noted that she had a yellowish, smelly vaginal
discharge. Ms A was concerned that her symptoms were caused
by the IUD.

Ms A was seen on this occasion by Dr D. During the consultation,
Ms A complained of lower abdominal pain, vaginal bleeding with
discharge, vomiting, diarrhoea and a general feeling of
discomfort. She was concerned about her state of health, and
told Dr D about her family history of ovarian and cervical
cancer. (Dr D recalled that it was not until Ms A's second
consultation on 5 October 2004 that he was informed of her family
history of cancer.)

Dr D documented that Ms A was feeling teary, and that she had
been experiencing abdominal pain with smelly and yellow-coloured
vaginal discharge. She did not have any pain when urinating.
On examination, she was afebrile, and her abdomen was normal
(not distended), although she had generalised pain in her lower
abdominal area. Dr D wanted to perform a vaginal examination
but Ms A declined an internal investigation. He documented in
his notes that "she is pushing my hand away".

A urine sample showed a trace of protein. Dr D did not
consider it necessary to order blood tests that night as there was
no after-hours pick-up of blood samples, and he had not detected
anything abnormal from his abdominal examination.

Dr D made a provisional diagnosis of pelvic inflammatory disease
(PID). He advised Ms A to return to Dr C in the next one to
two days to have her IUD removed, and to have a cervical smear and
cervical and vaginal swabs taken. He documented his follow-up
plan as "she also needs smears and swabs and was told about
that". To alleviate her vomiting and pain, Dr D gave her
intramuscular injections of Maxolon and Voltaren. She was
also prescribed oral analgesics, antibiotics and Maxolon.

Ms A did not return to Dr C as advised. Over the following
week, she continued having diarrhoea and vomiting. According
to her, the symptoms worsened "after each dose of the prescribed
medicines".

Consultation on 1 October 2004

Six days later, at approximately 2.30pm on 1 October 2004, Ms A
presented again to Dr C. Ms A complained of abdominal pain,
irregular menstrual bleeding and vaginal discharge. She
stated that she felt "terrible [and could] not remember ever
feeling so unwell". She informed Dr C of her decision to stop
the oral contraceptive pill as she was still having irregular
periods, and did not believe that the prescription was effective.
Ms A also told Dr C that she had stopped taking the
medication Dr D prescribed as it did not alleviate her diarrhoea
and vomiting.

After reviewing Ms A's clinical records, Dr C noted that she had
presented to Dr D six days earlier, and had been prescribed
antibiotics for probable PID. Dr C also noted that Dr D had advised
Ms A to attend a follow-up appointment with her in relation to the
smear, swabs and IUD removal.

Although it is not documented in Dr C's notes, she informed my
Office that she did examine Ms A's abdomen. She observed a
generalised tenderness without any abnormal organ enlargement or
rebound tenderness. Internal examination of Ms A's vagina and
cervix did not reveal any infection or unusual discharge. Her
uterus was tender but not acute. Dr C removed her IUD without
any difficulty and took a cervical smear. She explained that
cervical and vaginal swabs were not done as she did not observe any
smelly discharge during the IUD removal.

From her observations and examination, Dr C did not consider Ms
A to be dehydrated, jaundiced or anaemic. Dr C prescribed
medication to alleviate Ms A's abdominal pain, diarrhoea and
vomiting, and advised her to return if her symptoms did not settle
or the pain worsened.

Pre-consultation events on 5 October 2004

On 5 October 2004, Ms A sought medical attention from the
medical centre as she had difficulty breathing, and had
"excruciating pain" in her abdominal area. Her friend, Ms B, drove
her to the medical centre. On arrival at 6.13pm, the
receptionist gave Ms A a Triage Assessment Form to complete (see
Appendix 1). Ms A indicated on the form that she was having
severe pain/headache, and was directed to the triage area for an
initial nursing assessment.

Ms E was one of two nurses on duty that evening. She
recalled that the medical centre was particularly busy as several
patients had presented with injuries and emergency medical
conditions. Ms E was attending another patient in the plaster
bay when she saw Ms A in one of the nurses' stations.
According to Ms E, Ms A "did not appear to be in severe pain" and
"nothing in her appearance [was of] concern at that time".
When Ms E indicated to Ms A that she would be attended to shortly,
Ms B replied, "We're fine, we can see you are really busy."
Ms E informed them that they could approach her sooner if the need
arose.

Ms B has a different recollection. According to her, when
she asked about Ms A's expected waiting time before being triaged,
Ms E explained that the clinic was very busy and that she would
have to "wait [her] turn". Although Ms B recalled waiting for
approximately 15 minutes before Ms A was triaged, it was documented
on the triage form that Ms A was assessed at 6.20[pm],
approximately seven minutes after her arrival (see Appendix
1).

During the triage assessment, Ms E explained that she needed to
record some baseline observations including Ms A's blood
pressure. After two unsuccessful attempts with an automatic
machine, Ms A's blood pressure was recorded at 100/70mmHg using a
manual machine. Her pulse was 80 beats per minute and
temperature 36.8oC.

Ms E recalled being told that Ms A's pain was "coming in waves"
and that "she was getting another wave". She tried helping Ms
A onto the examination bed but was pushed away, as Ms A preferred
Ms B to assist her. As lying horizontally aggravated Ms A's
abdominal pain, the back of the bed was put in an upright
position.

Ms A was assessed as triage category 4 using the Australasian
Triage Scale. Patients in this category are considered to
have a semi-urgent medical condition, and should be seen by a
doctor within 60 minutes. Ms E explained that her assessment
was based on Ms A's complaint, appearance, demeanour, and the
clinical observations taken. Although she was aware that Ms A
was experiencing pain, she did not observe any pallor (pale
appearance to the skin) or sweating, and did not recall the pain
being described as "excruciating". According to Ms E, there
were no acute factors indicating that Ms A needed to be seen by a
doctor immediately. Ms E said that she would have arranged
for medical assistance sooner if Ms A's pain had appeared severe,
or Ms A had requested it.

While waiting for a doctor, Ms A requested pain relief. Ms
E explained that as there were no "standing orders", nurses were
unable to administer pain relief before a patient was seen by a
doctor. She checked on Ms A in between assessing other
patients. On one of these checks, approximately 15 minutes
after the triage assessment, Ms A complained that her pain was
worsening. Ms E told Ms A that she would inform Dr D
accordingly and request pain relief be charted.

Immediately after Dr D finished with a patient, Ms E went into
his consultation room and asked him to attend Ms A. He
indicated that he would see her. According to Ms E, Dr D
"poked his head briefly" into the cubicle where Ms A was, but she
could not hear what he was saying. Ms E observed him
returning to his consultation room without charting any pain
relief.

Ms B said that Dr D made a remark along the lines of "Oh, you
again. Didn't I see you the other day?" He then left to
attend to another patient. Ms B considered his comment
inappropriate. Dr D clarified:

"What I really meant and tried to say was that I was very
surprised to see her a week later, just as unwell and not being
seen earlier or being admitted by now. I did not mean for
this to be interpreted as it was."

Consultation on 5 October 2004

Ms A was seen by Dr D at 6.57pm. She was not brought to
his surgery room but remained in the triage cubicle for this
consultation. Ms A did not present with any diarrhoea or
vomiting but complained of pain "all over" her abdominal
area. Dr D noted that she had recurring abdominal pain which
was "coming in waves", and experienced back pain when lying
horizontally. He documented that her IUD had been removed,
and that she did not experience any abnormal symptoms when
urinating.

On examination, Ms A was afebrile and there was nothing abnormal
detected in her ears, nose, throat, chest or cardiovascular
system. Her abdomen was normal and not distended. Dr D
observed that she had generalised pain in her abdomen, which was
more acute in the upper right area. While palpating her
abdomen, Ms A pushed Dr D's hand away. He explained to Ms A
that he did not intend to order a blood test as there was no
collection of routine blood samples after hours. Dr D was
unable to perform CT and ultrasound scans during the consultation,
and advised Ms A to return to Dr C for further
investigations.

Ms B found Dr D's basic demeanour towards Ms A to be "abrupt and
condescending". Her impression was that Dr D considered Ms A
to be wasting his time when he had other patients to see.

Dr D queried whether Ms A's abdominal pain resulted from using
an IUD beyond the recommended duration, or could be explained by a
diagnosis of cholecystitis or diverticulitis. Although he
considered admitting Ms A to the Emergency Department of a public
hospital, he did not do so as he was uncertain about her expected
waiting time. Dr D advised Ms A to self-admit or to return to
the medical centre that evening if her condition worsened.
Alternatively, she was advised to see Dr C the following day.
Dr D recalled that Ms A "was happy with going home on pain
medication and to see her doctor the next day". In contrast,
Ms A expressed amazement that she "would be sent home in this much
pain".

To alleviate Ms A's symptoms, Dr D prescribed Tramal (an
analgesic) and Buscopan (an antispasmodic medication). She
was also given intramuscular injections of Buscopan and Tilcotil
(anti-inflammatory analgesic) by Ms F, registered nurse, who
explained that Ms A needed to remain for about 20 minutes for
further observation. According to Ms F, Ms A's pain appeared
to be intermittent as she was able to converse with Ms B.
While waiting for Dr D, Ms A complained about his decision to send
her home.

Dr D returned to see Ms A. She reiterated her
dissatisfaction with being sent home. According to Ms B, Dr D
"did not seem interested" and advised her to have blood tests and
CT and ultrasound scans when she saw Dr C the following day.
The consultation concluded at 7.03pm.

As they were leaving the medical centre, Ms B informed Ms F
about Ms A's "lack of improvement". Ms B recalled Ms F
advising them to call an ambulance or to go to a second medical
centre, which had a triage nurse on duty all night. Ms B
interpreted this to mean that Ms A would receive better medical
care at another medical centre. Ms F clarified that she had
mentioned the second medical centre as she was aware that Ms B was
dissatisfied with the care Ms A had received from the medical
centre that evening.

Post-consultation events on 5 October 2004

On the way home, Ms A and Ms B stopped to get the prescription
filled. As Ms A did not experience any improvement 50 minutes
after taking the medication, Ms B contacted the second medical
centre on her behalf. The nurse on duty advised her to return
to the medical centre or to call an ambulance.

Ms B telephoned Ms E to complain that the prescribed medication
was ineffective. Ms E said that she would convey Ms B's
concerns to Dr D.

Dr D recommended hospital admission. This was relayed to Ms
B. Ms E offered to arrange for an ambulance and to fax Ms A's
clinical records to the public hospital. Ms B indicated that she
would call the ambulance herself.

Ms A was transferred by ambulance to the public hospital that
evening. She was reviewed by a gynaecologist the following
day, and a decision was made to perform a laparotomy. The
operation on 6 October revealed peritonitis secondary to the
rupture of a tubo-ovarian abscess. Approximately 1.3 litres
of pus was drained from the peritoneal cavity. Ms A remained
in the high dependency unit for eight days as she developed
bilateral plural effusion (excessive fluid surrounding the
lungs). On 15 October, her condition stabilised, and she was
transferred to the general ward. Ms A had a slow
recovery and was discharged from hospital on 31 October 2004.

The medical centre's triage system

The medical centre's triage guidelines applicable at the
time Ms A received care were issued on 15 December 2002 and
reviewed on 20 December 2003. The guidelines describe the
initial assessment process and the triage scale used. The
guidelines define triage as:

"… the process by which walk-in or acute patients are allocated
a priority of care and area of treatment."

On arrival at reception, patients are requested to answer
questions on the Triage Assessment Form. If a patient circles
"yes" to having any of the acute symptoms listed on the form, the
receptionist is required to alert the triage nurse or to take the
patient to the treatment room to be seen by a doctor. The
guidelines place responsibility on the nurse to triage patients and
to assign a triage scale, and on the doctor to see the patient
within the waiting time corresponding to the assigned triage
scale.

The triage scale used by the medical centre is based on the
Australasian College of Emergency Medicine's recommendations.
The five levels of acuity (priority for assessment according to the
severity of presenting symptoms), corresponding codes and response
times for a patient to be seen by a doctor are:

The medical centre has a check system to ensure that new staff
are not rostered together. On the evening of 5 October 2004,
the medical and nursing staff on duty were all senior staff.
They also have a system of "call-back" doctors who are available to
work at short notice from 6pm on weekdays, all weekends and public
holidays. It is initiated by the doctor on duty or the senior
nurse, and is used on occasions when a junior doctor is on duty, or
when the waiting room is extremely busy. The call-back system
was not used on the evening of 5 October 2004 when Dr D was the
only doctor on duty.

The medical centre has since designed an electronic triage form,
which was implemented following a trial in May 2005. Their
new system enables all triage assessments to be recorded
electronically and audits to be conducted on the information
recorded

The medical centre's patient recall system

The medical centre had a patient recall system in place in 2004,
which staff continue to use in several ways. This includes
the doctor writing on the consultation notes "recall in 'x'-amount
of time". Following the return of test results, the doctor
may forward the report to a nurse and ask for the patient to be
recalled within a certain timeframe. Where a patient is
advised to attend a follow-up appointment, the patient is offered
an appointment time by the receptionist following his/her
consultation with the doctor.

At the time Ms A consulted Dr C in July 2004, the medical
centre's recall system was not programmed to record "DNAs" (did not
attend - missed appointments). Since then, improvements have
been implemented. The medical centre now document
electronically in the patient's notes, the patient's reason(s) for
missing appointments, along with any cancellations or rescheduled
appointments. In addition, the computerised system enables
the medical centre to audit staff members who cancel patients'
appointments.

Independent advice to Commissioner

The following expert advice was obtained from Dr Simon
Brokenshire, a general practitioner and senior medical officer in
an accident and medical centre:

"Statement of objectives:

I have been asked to provide independent
advice and comment to the Commissioner on a number of aspects
related to case 05/00985 which involved two separate doctors,
covering four separate consultations. I have also been asked to
comment on the triage processes of the clinic from where this
complaint arose.

I have read and agree to follow the Commissioner's Guidelines
for Independent Advisors.

Declaration of possible conflict of
interest:

I am unaware of any conflict of interest that I may have
regarding this case.

Qualifications:

MB ChB (Otago, 1984), Dip Obs (Akld,); Dip Com A&E (Akld,
1995)

FRNZCGP; FAMPA

Experience: I graduated in 1984 and went into
General Practice in 1990.

Over the following 10 years I worked in city, rural and
provincial settings.

With the increasing trend for general practice after-hours care
to be conducted out of an A&M setting, I chose to do further
training in this area of medicine obtaining my diploma in community
accident and medical practice, followed by my fellowship with
AMPA.

Over the last five years, I have devoted my time solely to
Accident and Medical care, working as a senior medical officer in a
busy A&M centre which sees some 60,000 patients a year.

Questions to be addressed:

These are multiple, and so to be concise and avoid repetition,
they will be outlined in the bulk of my response, heading up each
section.

This has been provided by the Health and Disability
Commissioner's Office and will not be repeated here.

SPECIFIC QUESTIONS AND ADVICE:

[Dr C]

1. Was [Dr C's] care and treatment of [Ms A] on 20
July 2004 adequate and appropriate?

I believe the care here was of an adequate
standard.

The presenting complaint was that of dysmenorrhoea, menorrhagia
and possibly irregular bleeding (recorded by [Ms A] in the [letter]
of 19/05/05).

The length of time of this problem is recorded as four months
and so appears not to be an acute problem. The notes record some
patient distress or frustration of such symptoms. There is also
reference to her concerns regarding her family history of ovarian
cancer.

Two positive issues of perceived importance by [Dr C] were the
IUD which was overdue for removal and may be a contributing factor
for her symptoms, and an overdue smear.

Negatives in the history not recorded are any inter-menstrual
bleeding or post-coital bleeding, no pregnancy symptoms, nor
mention of discharge even though treatment of such appeared in the
plan.

No examination was recorded, but in the plan the patient was to
return for further examination and removal of the IUD.

No baseline observations were recorded eg temperature, pulse, or
blood pressure. Nor was an abdominal examination recorded. No
pregnancy test was recorded.

Follow-up correspondence confirms that a number of these issues
were covered in the consultation but not recorded.

The plan included the return of the patient for full exam in two
weeks; but also involved the prescription of antibiotics,
analgesics and the combined oral contraceptive pill.

The reasoning for the antibiotics from subsequent correspondence
appears to be because there were some symptoms of a discharge and
it appears she was covering thrush and gardnerella. Also, it
appears that [Dr C] wished to provide some antibiotic cover prior
to the removal of the IUD (presumably covering the possibility of a
low-grade endometriosis or pelvic inflammatory disease.
(Although the metronidazole would also cover anaerobes, full cover
of possible bacteria (if one is concerned with pelvic inflammatory
disease) would not be covered by this combination eg chlamydia is
not covered.) Some practitioners I believe would not prescribe
antibiotics at this point (some would opt for the taking of swabs
prior to such and would not necessarily routinely cover with
antibiotics for the procedure of IUD removal).

The logic of the pill prescription is reasonable as it may
provide cycle control and ongoing contraceptive cover if this is
needed post removal of IUD. (Although high dose oestrogen may have
got more rapid bleeding control.)

The prescribing of the combined pill would require the checking
and informing of the safety profile of this drug in this particular
woman. No documentation of such is present in the notes but this
would be one's usual practice. This risk assessment I would regard
as being important especially as this patient was 37 years old and
who may possibly be overweight. There was no recorded blood
pressure reading.

Subsequent communication inferred that the patient had been on
an oral contraceptive before and it is implied that a risk
assessment occurred.

To proceed from here, the doctor might remove the IUD and take
swabs, cover with antibiotics if clinically indicated, and arrange
follow up where a repeat pelvic exam would occur and a smear taken
(when bleeding had stopped).

Or treatment may be instituted to obtain cycle control and
follow-up for IUD removal and smear at the next appointment.

Both options have their pros and cons.

There is some mention in the communications that there was some
patient reluctance to have an exam at that point in time.

The doctor may have been under time constraints as I would
imagine this consultation may well have been long up to the point
of considering a pelvic examination.

With these considerations, it seems reasonable to delay a full
exam for a future appointment if no acute signs had been elicited.
Also gaining control of bleeding is needed to perform an adequate
smear.

It was documented that the patient returns in 2 weeks for a full
exam, smear and IUD removal.

This is an important point.

In the patient's recall of events, she says she was to return
when the bleeding stopped which may not have occurred with any
degree of certainty.

The patient re-presented 2 months following this initial
consultation.

Either way, if the implied outcome was control of periods and
this did not occur, I would expect the patient to seek
clarification or present earlier.

Earlier follow up with the same practitioner may have resulted
in a different outcome.

The record of this consultation can be critiqued as all
consult[ation] records can be.

There appears to be some gaps, omissions, and some differences
in practice to that of the adviser's practice; however this
consultation is a complex one which involves a number of issues all
difficult to cover in an initial GP consult due to various
constraints.

These include the initial presenting complaints which require
some skill and time in teasing out and have a wide differential
diagnosis. There are issues around the IUD, an overdue smear,
possible discharge, the safe prescribing of the pill and
consideration of ongoing contraception post removal of the IUD,
along with the safe prescribing of a non-steroidal
anti-inflammatory analgesic. Also there are the issues of patient's
fears, concerns and frustrations as they have often put up with
symptoms for some time prior to seeking assistance. They come with
significant expectation and often a wish for a rapid resolution of
the problem.

On reflection therefore the standard of care within this
consultation is deemed to be of an acceptable
standard.

2. Was
[Dr C's] care and treatment of [Ms A] on 1 October 2004 adequate
and appropriate?

My conclusion was that on this occasion care and
treatment did not reach an acceptable
standard to a mild - moderate
degree but it was complicated by a number of confounding
factors.

This consult reflects a follow-up and carrying out of the
initial plan of 20/07/04; as well as a review of a more acute
presentation to another doctor 6 days earlier (25/09/04).

It appears that there is an assumption that this consult[ation]
six days earlier was a more acute presentation of
the chronic problem.

I assume these notes were fully available. The consulting doctor
of 6 days earlier suggested this current follow up and to continue
with the plan of removal of the IUD and smear and had started
antibiotics to cover possible pelvic inflammatory disease or
endometriosis. These however had been discontinued due to nausea
and diarrhoea.

The consultation notes on this occasion are legible yet
brief.

They allude to a possible intolerance (nausea and vomiting)
to medication prescribed 6 days earlier at her more acute
presentation.

The only other documentation is that of the IUD removal and
taking of the smear.

A medical certificate is issued.

Details are entered for the smear register.

A prescription for an anti-inflammatory analgesic, Imodium
and Stemetil were given for presumptive ongoing pain, and
intolerance to previous medications prescribed six days earlier (to
counter by the above anti-nausea and anti-diarrhoeal
medication).

Important Issues:

The timing of representation (3rd
consultation)

The timing of this re-presentation places a further strain on
the provision of medical services in a timely fashion, it being on
a Friday. A further weekend is coming. Doctors are generally busier
and under more pressure on a Friday so time and communication may
not be as optimal as it may be earlier in the week. Notes may not
be as good due to these factors. Investigations on a semi-acute
basis are more difficult to arrange along with the obtaining of the
results of such.

Patient factors, perceptions and concerns re finances are
accepted as barriers to timely review and intervention. These are
difficult and fraught issues.

However again I find there to be an anomaly between [Ms A's]
degree of perceived illness and discomfort (eg in her being unable
to attend work), yet seeking medical assistance some 6 days after a
more acute presentation despite being advised to do so earlier.

Brevity of notes which are not of acceptable standard
and reflect some omissions of practice.

Audit of the notes of this consultation in isolation is critical
of the brevity.

Important omissions were:

- Clarification and expansion of the more acute history over the
preceding 7 to 10 days;

- A lack of observations noted.

- Lack of documentation of the abdominal, rectal and pelvic
exams.

- No swabs taken or IUD sent for microbiological
examination.

- No pregnancy test or urine analysis.

- Although this patient may have been a difficult historian and
difficult to examine, full cognisance of her discomfort, her
re-presentation, and the previous doctor's assessment were needed,
so consideration of other possible diagnoses to account for her
symptom complex could be made.

Assessment of acuity and degree of
illness

This is at times very difficult for all practitioners especially
primary care physicians who are seeing the progression of disease
from its early stages.

The notes do not appear to take cognisance of the earlier acute
presentation on the prior weekend in terms of patient discomfort
and malaise. [Dr C] upon follow-up did not feel the patient was
acutely unwell. This appears to be based on her general impression
which is valuable but is not backed up by baseline observations nor
documented abdominal findings. I understand that this patient was
obese which makes abdominal findings especially pelvic findings
more difficult. The converse of this is that a higher index of
suspicion is needed. No comment was made of adnexal masses nor
cervical excitation. (Either positive or negative.)

Full consideration of patient's perceived distress,
other possible differential diagnoses and the need for further
investigation?

I think swabs and the sending of the IUD for microbiological
exam should have been done. This has been my standard practice.

[Dr C] at her initial consultation chose to put this patient on
antibiotics due to the possibility of a low grade infection. It
follows then to carry through and send samples away, particularly
in someone who has re-presented in abdominal discomfort. (Third
presentation albeit somewhat delayed.) Also at the preceding
consultation six days prior, pelvic inflammatory disease was a
possible diagnosis. The prescribed antibiotics of 6 days earlier
were seemingly poorly tolerated and they had been discontinued
prior to this current consultation. No further antibiotics were
prescribed apparently as there was no discharge present; there was
not the perception of being acutely unwell, and because of the
perceived intolerance to the recent antibiotics.

Faeces for culture and clostridium difficile may have been
considered.

Blood [tests] at this point are arguable but based on chronicity
of illness and perceived increasing acuteness of presentation,
blood [tests] may have assisted or reassured.

Note that obtaining the results in a timely fashion on a busy
Friday is often difficult in primary care.

I doubt that either swabs or blood [tests] would in the short
term have assisted greatly in a change of treatment or plan, but
may have assisted future consults should this occur eg over the
upcoming weekend. (Unless for example, a very high white count or
CRP [C-reactive protein] were returned suggesting infection rather
than dysmenorrhoea due to [the] IUD.)

A pelvic ultrasound would probably not have been indicated on
the documented findings at this point in time unless the suspicion
was raised that something else was happening here. However one
might have been considering this in view of the previous working
diagnosis of PID, where antibiotics were not being tolerated and
although there were no acute abdominal signs, there
appeared to be some generalised discomfort and comment was made of
a tender uterus.

If one was considering other tubo-ovarian problems,
retroperitoneal or possibly bowel pathology eg a diverticular
abscess or appendicitis, then it may have assisted.

Access to such may have been difficult especially so on a Friday
and would generally be requested if there was a perception of a
higher acuity or becoming more unwell.

If the only way to get an ultrasound in this locality at this
time of presentation was admission to hospital, I do not believe
this was warranted at this point in time, but would be considered
if rapid improvement did not occur.

One must remember that it was the working assumption that the
removal of the IUD was going to reduce symptoms.

Were there signs of other pathology, sepsis or acute illness at
this point in time? It appears not.

3. Are
[Dr C's] clinical records of an appropriate standard? If not,
why not? Please also comment on the appropriateness of the
notes in terms of communicating to other providers involved in [Ms
A's] care.

The clinical records are legible as they are
computerised in this practice.

The clinical records on the 20 July 2004 are of
an acceptable standard albeit with the
comments made in my reply to question 1.

The clinical records on the 1 October 2004 are
not of an acceptable standard and my reasons
for this conclusion are outlined in question 2.

In terms of communicating to other providers involved in
[Ms A's] care, the consult of 1 October 2004 is
lacking.

Examples of why I feel the notes of the consultation of
1/10/04 are not up to standard include the following:

Audit of the notes of this consultation in isolation is
critical of the brevity.

Little in the way of clarifying and documenting the history
of this illness eg to clarify the onset of the gastrointestinal
symptoms which probably predated the scripting of antibiotics six
days earlier.

Clarification and documentation of the problem which
appeared to have changed from dysmenorrhoea and menorrhagia to more
generalised abdominal discomfort with associated diarrhoea and
vomiting.

No comment is made of baseline observations, general
appearance or impression of the patient's wellness, abdominal
examination findings, speculum findings, pelvic examination
findings, whether swabs were taken (antibiotics were possibly still
being taken - this is not documented positively or negatively), the
sending of the IUD for microbiological examination.

A further plan may have been outlined but this was not
documented and therefore not communicated to future medical
staff.

In terms of communicating to future providers the notes of this
consultation would leave a future doctor unclear of [Dr C's]
impression and in fact leaves me with an impression of a routine
consult for a smear and removal of an IUD rather than a somewhat
more acute [and] chronic problem.

There is no conveyance of impression of the degree of
illness.

Nor, more importantly, is there a full documentation of intimate
exams of which there are sometimes some reluctance to be repeated
on behalf of the patient or future doctor.

On a number of occasions in the notes, there has been an
expression of patient reluctance to have a pelvic exam making it
more important to have this information communicated for other
doctors when it was done.

4. Should any other investigations or tests have been
ordered by [Dr C] at the consultation on 20 July 2004? If
yes, please explain.

In the context of the consultation and plan, I do not believe
any other investigations or tests were crucial at this point.

The appropriate excerpt from question 1 is as follows:

It was documented that the patient returns for a full exam,
smear and IUD removal.

An MSU dip stick and pregnancy test may have been considered
but the complaint was not of general abdominal pain but rather
dysmenorrhoea and menorrhagia although irregular periods may prompt
this test.

5. Should any other investigations or tests have been
ordered by [Dr C] at the consultation on 1 October 2004? If
yes, please explain.

I think swabs and the sending of the IUD for microbiological
exam should have been done.

Faeces for culture and clostridium difficle should have been
considered.

Bloods at this point are arguable and based on chronicity of
illness and perceived acuteness of this presentation. Due to the
protracted history bloods may have assisted or reassured.

A pelvic ultrasound might have been considered, but it is
arguable as to [whether] it was definitely indicated at this point.
On consideration of symptoms and protracted history, an abdominal
ultrasound might have been reassuring but on signs, there appeared
little to justify it acutely, unless the suspicion was raised that
something else was happening here. See comments
re[garding] ultrasound in my reply to question 2.

Note - A confounding factor here was the timing of seeking
advice and assistance. Had [Ms A] presented earlier in the week as
opposed to the following Friday, the IUD could have been removed,
then if she had not improved, blood [tests] and an ultrasound may
have been considered on a semi-acute basis prior to the
weekend.

I do not expect patients to take these factors into account but
they are confounding factors affecting the provision of a good
medical service.

6. Should [Dr C] have referred [Ms A] for assessment by
a gynaecologist?

[Dr C] saw this woman on two occasions.

On the first occasion, there were no indications to refer at
this point.

On the second occasion, 1 October 2004, this was the third
consultation for this problem but was also the completion of the
initial plan of removal of the IUD.

Her condition was assessed as not being acute although the
problem was developing some chronicity.

Examination revealed no indications for referral at this
point.

Also note that this second consultation of [Dr C] was on a
Friday and the most likely only option for referral was acutely to
hospital.

It is my opinion that this was not indicated at this
point in time.

[Dr D]

1. Was
[Dr D's] care and treatment of [Ms A] on 25 September 2004 adequate
and appropriate?

My conclusion was that on this occasion care and
treatment reached an acceptable standard.

There are some points of discussion that I would raise in
critiquing the record of the consult.

This consultation was complicated by a number of confounding
factors.

I have some concern as to the assessment of acuity and degree of
illness with a lack of recording of specific baseline observations
yet documentation of general observations eg malaise and
pallor.

This was confounded by annotation of the abdominal examination
in a non-standard manner.

There was no documentation of a pregnancy test having been
done.

The failure to conduct a pelvic exam due to the patient's lack
of consent compounded the sequence of events.

It is unknown if the importance of this exam was impressed upon
the patient.

Swabs would have been useful to confirm the working diagnosis of
PID and the IUD could have been removed.

The prescribed antibiotic treatment would not have covered
chlamydia.

This consultation took place on a Saturday (no time recorded on
notes).

It appears to be an acute or acute and chronic presentation of
lower abdominal pain. This is the second visit to this clinic, her
first being to her GP some two months earlier. The plan then was to
be seen two weeks following this first consultation for removal of
IUD and smear. These notes I assume were available.

The history and review of systems appears adequate although
there are some gaps in documentation.

Baseline observations were recorded as normal but the only
specific one documented was that of a temperature of
37.7oC.

General observations of 'pallor, miserable and sick and teary'
[were] made.

These strike me as important comments. 'Pallor' used medically
is a significant observation. The other observations are subjective
but imply some degree of empathy given by the doctor but also a
degree of distress imparted by the patient.

Follow-up comment was made of an apparent lack of distress or
marked discomfort with the patient lying semi-recumbent and talking
easily. People in marked distress often do not verbalise well.

Urine exam reveals a trace of protein, there is no mention of
pregnancy test result.

Documentation of the abdominal exam appears ambiguous and leaves
the reader with some uncertainty. [For example,] 'Sore all
over, more so lower and is pushing my hand away.'

'Pushing my hand away' gives an impression that the patient was
in reasonable discomfort and possibly not understanding the
importance of such an exam and the need for some co-operation.

The documentation is not standard and so the communication of
the signs to another doctor and the impression that [Dr D] had is
unclear.

Explanations for such are many, and can take in patient and
doctor factors.

Generally speaking, it is difficult to establish if this
examination met the required standard. Documentation should be
relatively standard and outline any difficulty in obtaining the
information due to eg patient discomfort or compliance.

Standard notation should outline if the abdomen was soft,
tender, any masses, any organomegaly, bowel sound quality, any
signs of peritonism eg percussive tenderness, rebound and guarding;
along with rectal and pelvic exams.

It was documented that the patient refused a pelvic examination
which I regard as significant. As to how hard this issue was pushed
by [Dr D] is unknown.

I regard this exam along with a rectal examination as important
in a woman of reproductive age with lower abdominal pain.

I note in the patient's recall of events she comments that 'he
did say the IUD had to come out but did not suggest it be done
then'.

With a working diagnosis of PID swabs are important.

Ideally this patient should have had a full pelvic examination
with swabs, removal of IUD, palpation for masses and attempt to
illicit cervical excitation, along with a smear.

(Note however that even if a pelvic exam had been done,
signs of pelvic pathology are often difficult to detect especially
in a woman of larger habitus, particularly the palpation of masses,
however obtaining the samples would assist subsequent
consultations.)

[Dr D] on follow-up communication discusses the issue of blood
[tests] and that he felt they were unlikely to add significantly to
his clinical assessment. Also, he commented on the apparent
difficulty in obtaining semi-acute blood results in his setting out
of normal working hours.

It is easy in retrospect, but if there was some uncertainty as
to the diagnosis, chronicity or acuteness of this presentation a
FBC [full blood count] and CRP [C-reactive protein] may have given
a pointer or alert toward this.

If a pelvic examination had elicited any signs of concern, then
consideration of an ultrasound may have occurred at this time.

The ability to get semi-urgent investigations may not have been
easy after-hours in this setting.

[Dr D] is regarded as a senior doctor who had done his training
in Accident and Medical practice. I would assume that there were no
acute signs that caused him concern.

Also the fact that it was not [considered] necessary to do any
bloods, refer for observation, a second opinion or ultrasound it is
the impression that the degree of assessed illness and acuity was
not acute and that analgesia and antibiotics may well contain the
illness if not solve the problem.

The documented refusal to have a pelvic exam meant that the
doctor had to make an educated guess as to possible pathology.

[Dr D] outlined his differential diagnosis of PID, IUD causing
problems, abdo[minal] pain of other origin; and his plan was for
clinical review by her GP following the weekend, possibly the next
day. Analgesia and an antiemetic were provided.

Antibiotics to cover possible PID was given. Note this
combination would not cover all possible causes. eg chlamydia would
not be covered.

[Dr D] outlined in his follow-up notes that he had mentioned
possible hospital review if she did not improve.

On balance in spite of the reservations outlined, I feel that
overall care and treatment here was of an acceptable standard.

2. Was
[Dr D's] care and treatment of [Ms A] on 5 October 2004 adequate
and appropriate?

My conclusion is that on this occasion care and treatment
did notreach an acceptable standard
but only failed to a minor degree.

This consultation was complicated by a number of confounding
factors.

The principal issue here is the recognition of how unwell the
patient was perceived to be, the acuity of such, and need for
tertiary service referral in someone where the disease process is
evolving with time.

I believe [on] balance, it would have been more prudent to have
admitted this woman for ongoing observation and a second
opinion.

I do not believe that the protracted history (this being the
fourth consultation) was given enough weight; the notes documenting
her abdominal signs were not of a reasonable standard and cast some
concern over the adequacy of the examination.

Non-standard terminology was used similar to that used in this
doctor's previous consultation.

There is no documentation of any abdominal masses, guarding,
rebound or percussive tenderness. Bowel sounds are recorded as
normal. These later signs, if present, would be indicative of acute
pathology and possible peritoneal inflammation and would suggest
that hospital review would be prudent.

Rectal and pelvic exam were not performed. A pregnancy test was
not documented.

In view of the re-presentation of this patient, the lack of a
firm diagnosis and the discomfort the patient appeared to be in,
further observation and investigation may have been prudent to
initiate.

These depend on what is available in the setting.

Urgent bloods, imaging (an ultrasound or CT) or referral for a
second opinion with view to possible laparoscopy/laparotomy would
be considerations.

This however depends on the assessment of acuity and degree of
current illness, and the need for urgent investigation as opposed
to semi-urgent investigation during normal working hours. Referral
may be dependent on local knowledge of the likelihood of these
investigations occurring on an acute basis.

The documented plan was to provide analgesia, admission to
hospital overnight if no better or GP review in the morning.

Analgesia was provided, the initial choice of such seemingly
appropriate.

Despite this, the patient reportedly remained distressed.
However I feel there is conflicting evidence of the patient's
condition and I believe it was difficult at this point in time to
identify her developing
illness.

It appears that the baseline observations showed no evidence of
severe illness, that the triage nurse's opinion was not that of
someone markedly unwell, (the initial triage nurse assessment was
carried out by an experienced nurse of over 10 years standing).

The second nurse to be involved who provided the patient with IM
[intramuscular] analgesia made no comment in her notes to allow
objective or subjective conclusions to be drawn as to concerns
re[garding] [Ms A's] continuing condition or the need for further
review or observation.

It appears there was some concern being voiced by [Ms A's]
friend as to the care provided and [Ms A's] continued discomfort.
Second opinion options were given and the complaint procedure was
outlined.

There appears to be some debate as to what was meant or inferred
by these comments.

The doctor's notes are ambiguous re[garding] these issues.

However, a period of observation beyond the routine 20 minutes
may have been warranted if there were any concerns from medical,
nursing, patient or patient's advocate as to persisting discomfort
or distress.

If inadequate response to analgesia had resulted then narcotic
analgesia may have been an option.

The plan elected was to return home which may have been
reasonable if social supports were adequate and that the patient
and her carer were on board with this plan. Also, they needed to be
clear as to what to do if things did not improve. One solution that
sometimes satisfies a patient is access to the doctor should
problems occur ie being given permission to phone back and talking
directly to the doctor.

Social issues may preclude returning home and such a plan and
again, ongoing observation in hospital or in the clinic may have
been elected.

These suggestions are very easy to make in retrospect and may be
entirely impractical to the setting in question.

The decision by the doctor not to admit, it seems, was partly
made on the past experience of long delays for patients seen in the
hospital's Emergency Department.

This I believe [the above] is an erroneous assumption and should
not be considered if ideally the patient would be better
investigated and observed [in a hospital setting].

If hospital review was considered, the pressures the hospital
system is under is of no real concern to primary care.

However I do not believe the course of
action that was chosen altered the outcome of the disease or its
progress. Had this woman been seen and admitted directly, I do not
believe that her outcome and subsequent experience would have been
significantly different.

In reality, there was no significant time delay in reaching
hospital care in this case when she communicated that she was not
improving.

(She was in the clinic for just under two hours, departed at
2000hrs and rang the clinic at 2030[hrs] to convey that she was no
better. She was advised to go to hospital at this point.)

Transportation issues are said to have been discussed suggesting
an ambulance be called.

Notes were faxed to the hospital.

Note that admission observations to the Emergency Department
showed [Ms A] to be febrile, tachycardic, and in moderate
distress.

I believe that this patient suffered considerable distress from
a significant illness that resulted in peritonitis and possible
generalised sepsis. She required some time to recuperate and
rehabilitate from her illness.

It appears her experience of the care received on the night of
admission was below her expectations.

This was in the context of pain, distress, anxiety and
reflection after such an ordeal that this complaint was made.

Some of this complaint related to how she perceived she was
dealt with on a human level and the manner in which she perceived
her care was delivered.

These issues are always fraught and related to memory of events,
opinion, conjecture, interpretation and misinterpretation. They
have not on this occasion been part of the assessment for this
complaint, but I am mentioning them as I believe they formed a
significant basis for the complaint.

My analysis of the notes, processes and procedures conclude that
[Ms A] did not receive care to a reasonable standard from a medical
point of view, but due to confounding factors, I believe this
deviation from an acceptable standard is of a minor nature and
probably did not affect the outcome of the disease process.

3. Are [Dr D's] clinical records of an appropriate
standard? If not, why not? Please also comment on the
appropriateness of the notes in terms of communicating with other
providers involved in [Ms A's] care.

Generally [Dr D's] notes are of a reasonable standard and
provide a reasonable record to communicate his thoughts to future
members of the health team.

[Dr D's] notes are legible and relatively full with reasonable
documentation of review of systems.

I have made past comment on some non-standard annotation of
his examination findings regarding important negatives and
generalised acceptable nomenclature.

Specifically, his notes relating to abdominal examination were
not what I regard as standard and left the reader uncertain as to
the exact findings.

I think doctors working in A&M settings or GPs seeing other
doctors' patients need to be even more vigilant re[garding] their
documentation of baseline observations and general impressions of
[a] patient's acuity and degree of illness.

A clear plan needs to be outlined often with an expected time
scale.

This obviously needs to be communicated to the patient.

In some settings, patients would be given a copy of the
notes.

4. Should [Dr D] have referred [Ms A] to a gynaecologist
on 25 September 2004?

No, I do not believe such referral was indicated at this point
in time.

It was reasonable to assume the original plan of removal of IUD
and clinical review at this point. It was assumed that review would
occur in the subsequent few days.

Yes, I believe that having assessed [Ms A] as not being acutely
unwell, and her having refused a vaginal exam, (that would have
enabled further assessment and hastened the removal of the IUD),
then early review by her own GP was appropriate. (Assuming no rapid
deterioration in her condition occurred.)

Ideally, this should have been early in the week following this
weekend consultation.

In reality it took place some 6 days later (on a Friday).

As to whether the suggested plan of early review was clearly
communicated is uncertain, but certainly this is documented in the
medical plan.

As already outlined, the issue was an assessment of acuity and
the degree of illness.

A firm or confident diagnosis was not made at this point.

Although I think the specific diagnosis of a pelvic abscess may
have been difficult to make, it bothered me that this was the
fourth presentation and a firm diagnosis was still uncertain.

Secondly, the diagnosis as such was not necessary as long as one
could be confident of the assessment of acuity and developing
illness.

It is easy to say in retrospect that the assessment by the
health team was wrong and that the patient warranted admission to
hospital.

However, there were minimal documented objective signs of high
acuity at the time of assessment.

One must also consider the fact that primary care is seeing
illness in progress and often sees more subtle, early signs that
then develop.

The observations made 1-2 hours later showed evidence of
developing illness with more acute signs (fever, tachycardia, and
increasing distress).

Factors that in retrospect may have swayed the decision to
admit:

The degree of discomfort and distress that [Ms A] appeared to
be in which did not abate with analgesia after a short period of
observation.

The possible associated chronicity of events.

The absence of a confident diagnosis.

The possible need to observe for longer and do some baseline
investigations that may assist in clarifying the clinical
picture.

Psycho-social issues eg support, patient or carer anxiety and
concern etc that would make admission a more viable option.

Patient's previous demonstration of not being followed up as
requested.

The impression I got from the notes was that admission was going
to be likely. This should have then been expedited.

Note - Each patient's situation must be
assessed uniquely but other confounding factors are always at
play.

It appears from all people's notes that the clinic was busy with
other unwell patients.

There would have been some pressure on limited staff.

A review of the appointment list on the night in question showed
[that] in the half hour that [Ms A] presented (15 minutes either
side), five other people presented and these included a person with
a laceration to the head and a person with chest pain.

In each specific setting in New Zealand, there are different
degrees of threshold to admit.

These involve many issues surrounding what investigations or
services will be provided at certain hours of the day. These
factors may also influence one's decision.

We do not as primary care physicians wish to place secondary
care under undue pressure dealing with things that may be better
sorted out on a semi-acute basis.

These are all confounding factors but not excuses.

I think in balance that this patient warranted further
observation and admission was prudent.

This however is not black and white and I do not
regard the decision not to admit as a major departure in standard
of care.

Advice was given to be admitted if any deterioration occurred.
This happened 30-60 minutes after leaving the clinic. Admission
occurred.

This short period of delay, I believe would not have affected
the clinical outcome.

7. Should
[Dr D] have referred [Ms A] to a gynaecologist on 5 October
2005?

This has been largely dealt with in [the] preceding
questions.

The time of day and referral services available would dictate
what was possible, but most likely the only choice was acute
hospital assessment.

Specific gynaecological referral I believe was not the issue as
a firm diagnosis was not at this point made.

The issue was tertiary acute assessment - as opposed to
gynaecological or surgical referral.

This question has been dealt with.

8. Were [Dr D's] follow-up arrangements for [Ms A] on
the evening of 5 October 2004 appropriate? If not, why
not?

The plan for the subsequent 24 hours appears clearly documented
in the notes.

It appears however, that this plan was not well communicated or
accepted by the patient or her carer.

A clearer plan with the patient in agreement may well have made
her feel listened to, and a more active participant in the options
that may have been available.

Some patients are reluctant to go to hospital when it is felt to
be highly indicated by medical staff.

Others are keener to be reviewed even if medical staff feels
there is no absolute need for such at a certain point in time.

Discussion of the options which were relatively limited may have
assisted this situation. Namely:

- Home and review if
no better after 'x' amount of time by phone or in person.

- Further observation
in the clinic (if time, staff and space allowed).

- Admission to
hospital.

[The medical centre]

1. Does
[the medical centre's] triage system comply with relevant standards
for Accident and Medical clinics? If not, why
not?

I think that the paper system used in this case could be
improved upon, especially in documenting evidence to justify the
assigned triage code.

For example, documentation of observations and a brief history,
exam or nurse initiated investigations and interventions including
pain relief (standing orders).

Such a system, I understand, was in the process of development
and a computerised system has now been trialled.

The computerised annotation of time on the daily record of
all documentation from triage, to
consultation, to the administration of medication, I think would be
an improvement in the system, but this is dictated in part by the
computer system and IT company.

[The medical centre] have I believe, satisfied the requirements
of the standard and would have had their systems audited to have
obtained an ACC endorsement as a Level 2 A&M clinic along with
the associated A&M contract.

2. Was [Ms A] adequately and appropriately triaged on
the evening of 5 October 2004? If not, why not?

Yes, I believe that [Ms A] was adequately and appropriately
triaged on the 5/10/05.

The time line recorded showed that she was seen within
acceptable time limits, she was assessed and a triage code was
allocated that would fit with the Australasian College for
Emergency Medicine's triage scale.

One could argue that she may fit into category 3 or 4 but she
was seen within an acceptable time either way.

My comments regarding documentation of triage as per question 1
are relevant here. Baseline observations, a brief history along
with general appearance, distress and perceived acuity and degree
of illness are important aspects to effective triage.

These I believe were done on this occasion."

Code of Health and Disability Services Consumers'
Rights

The following Rights in the Code of Health and Disability
Services Consumers' Rights are applicable to this complaint:

RIGHT 4

Right to Services of an
Appropriate Standard

1) Every consumer has
the right to have services provided with reasonable care and
skill.

2) Every consumer has
the right to have services provided that comply with legal,
professional, ethical, and other relevant standards.

…

5) Every consumer has the right to co-operation among
providers to ensure quality and continuity of services.

Relevant standards

The Medical Council of New Zealand's publication Good
Medical Practice - A Guide for Doctors (2003) states that
doctors must:

"keep clear, accurate, and contemporaneous patient records that
report the relevant clinical findings, the decisions made, the
information given to patients and any drugs or other treatment
prescribed."

Outcome: Triage occurs in a timely and
effective manner in line with current best practice.

Note:
For the purpose of this Standard, triage is defined as an initial
assessment of the severity of the consumer's condition, in order to
determine priority of treatment."[2]

Opinion: Breach - Dr C

Care and treatment

Right 4(1) of the Code of Health and Disability Services
Consumers' Rights (the Code) states that patients have the right to
have services provided with reasonable care and skill. Ms A
consulted Dr C on two occasions: on Tuesday 20 July 2004 when she
first presented with dysmenorrhoea and menorrhagia; and on Friday 1
October 2004 when she continued to be troubled by abdominal pain,
irregular menstrual bleeding and smelly vaginal discharge.
Between these consultations, Ms A had also presented after-hours to
Dr D on 25 September 2004, with similar symptoms.

Care and treatment on 20 July 2004

My expert, Dr Simon Brokenshire, considered the visit on 20 July
to be a complex consultation involving a number of issues that were
difficult to cover adequately in an initial consultation. Ms
A presented with dysmenorrhoea, menorrhagia and possibly irregular
bleeding of four months' duration, all of which require skill and
time to investigate further, with several possible diagnoses.
There were issues concerning the removal of her IUD, overdue
cervical smear, safe prescription of the oral contraceptive pill,
ongoing contraception following the IUD removal, along with the
safe prescribing of a non-steroidal anti-inflammatory analgesic.
Given the duration Ms A had put up with her symptoms prior to
seeking medical attention, it is likely that she came with fears,
concerns, frustrations and an expectation that her symptoms would
be rapidly resolved. Dr C described her as "very tearful" and
noted that she had exceeded her threshold for handling the pain.

Dr C's examination focused on Ms A's abdominal area. There
were no lumps or areas of tenderness, and she had normal bowel
sounds. However, Dr C did not document the findings in her
clinical records (a matter commented on separately below). I
note her explanation that Ms A was experiencing heavy menstrual
bleeding and was reluctant to have an internal pelvic investigation
or vaginal and cervical swabs. Dr C's plan was to schedule
the internal pelvic examination and swabs a fortnight later when Ms
A returned to have her cervical smear and IUD removed. An
appointment was made for 3 August 2004.

Although postponing the internal pelvic examination and swabs
was reasonable in the circumstances, Dr C needed to emphasise the
urgency of an internal pelvic investigation (given Ms A's symptoms
and IUD of six years' duration) and to document that she had done
so. Dr C should also have documented Ms A's refusal to have
swabs and a pelvic examination. Such notes serve as a
follow-up reminder during the next consultation and are useful in
the event Ms A is subsequently seen by another doctor (as
eventuated). There is no indication from Dr C's clinical records
that she advised Ms A about the importance of swabs and a pelvic
investigation.

My expert pointed out that there were several gaps and omissions
during this consultation. While oral contraceptives are
appropriate for treating dysmenorrhoea and menorrhagia, Dr C should
have assessed and discussed the risks and benefits of taking
Marvelon (a third generation combined oral contraceptive) before
prescribing it. A risk assessment was especially important as
Ms A was in her late thirties and was overweight. A woman
with a personal or family history of blood clots or severe varicose
veins, or who is overweight, has a higher risk of developing blood
clots if prescribed the oral contraceptive pill, and the risk is
greater with third generation pills such as Marvelon.[3] It is unclear whether a risk assessment
took place or whether the risks were discussed with Ms A,[4] as Dr C did not record any discussion on this
matter.

My expert commented that some practitioners would not prescribe
antibiotics and antifungal cream to treat gardnerella and
thrush-like symptoms without taking vaginal and cervical
swabs. Given that Dr C was attempting to treat a possible
infection in the genital area, it would have been prudent for her
to take vaginal and cervical swabs before prescribing Ms A with
antibiotics and antifungal cream. The swabs would have
confirmed the type of organisms present in Ms A's vagina and/or
cervix and enabled Dr C to treat her symptoms more
effectively. However, as noted above, Ms A was reluctant to
have swabs taken.

Notwithstanding the gaps and omissions, I accept my expert's
view that Dr C provided a satisfactory standard of care on 20 July
2004 and did not breach Right 4(1) of the Code. I accept that
this was a complex consultation, which placed Dr C under tight time
constraints, and that it was difficult examining and treating a
distressed patient.

Care and treatment on 1 October 2004

Ms A did not attend the booked follow-up appointment a fortnight
later (in early August 2004) but returned to see a doctor two
months later on 25 September 2004. I note Dr C's comment that
if Ms A had presented earlier, the outcome may not have been as
severe. My expert also commented that earlier follow-up with
Dr C could have led to a different outcome. It is unclear why
Ms A did not attend her scheduled appointment with Dr C. It
may have been prudent for Dr C to have taken steps to follow up
with Ms A after the two-week period and to document her actions,
although the procedures were not urgent. If the medical centre had
an efficient patient recall system in place, the practice nurse or
the receptionist could have been prompted to contact Ms A to remind
her that she had missed her appointment and needed to make another
appointment for IUD removal and a cervical smear. However, I accept
that patients have some responsibility for their own care, and that
this includes attending booked appointments for follow-up
procedures.

When Ms A returned for a second consultation on 25 September,
she saw Dr D. I agree with Dr C's comment that continuity of
care is compromised when a patient receives care from different
doctors. Dr D advised Ms A to return to Dr C within the next
one to two days, but she did not present again until six days later
on 1 October 2004. Whatever her reasons, Ms A delayed seeking
medical attention despite being advised to do so.

On 1 October, Dr C removed Ms A's IUD and carried out a cervical
smear according to the follow-up plan of 20 July. She also
performed an abdominal and internal pelvic examination, although
her findings were not documented. During the consultation, Ms
A complained that she experienced diarrhoea and vomiting after
taking the medication Dr D prescribed. She also felt very
unwell. Although Dr C was aware from reviewing the treatment
records that Ms A had seen another doctor on 25 September, her
notes do not appear to take into account the acute symptoms with
which Ms A had presented to Dr D.

Dr C did not consider Ms A to be acutely unwell after examining
her abdomen and pelvis. My expert commented that it is more
difficult to detect abnormalities from performing abdominal and
pelvic examinations in overweight patients. I agree with my
expert that Dr C should have adopted a higher degree of suspicion
during her examination. While Ms A may have been a reluctant
patient, Dr C should have been more attentive to Ms A's complaints
and discomfort, and queried the reasons for her recent visit to Dr
D. Taking these steps would have assisted her in considering
other possible diagnoses for Ms A's multiple symptoms.

Dr C advised that she did not take vaginal and cervical swabs as
there was no smelly discharge present when Ms A's IUD was
removed. Given that Dr C had previously considered the
possibility of a low-grade genital infection, and Ms A had
re-presented with ongoing abdominal discomfort on 1 October, my
expert advised that swabs should have been taken. Dr
Brokenshire also considered that blood and stool tests for
microbiological organisms would have been appropriate given Ms A's
acute ongoing symptoms. While these investigations may not
have led to a change of treatment, the results would have been
beneficial for subsequent follow-up care. It would have been
prudent for Dr C to investigate Dr D's provisional diagnosis of
pelvic inflammatory disease by sending Ms A's IUD for
microbiological examination. Dr C should also have considered
the need for a pelvic ultrasound since Ms A's uterus was tender on
examination, and she had complained of a generalised abdominal
discomfort. Her adverse reactions to antibiotics should have
alerted Dr C to the fact that the pelvic infection was not
responding to Dr D's prescription, and necessitated additional
investigation on her part, such as ordering an ESR (erythrocyte
sedimentation rate). In my view, Dr C did not investigate Ms
A's symptoms adequately on 1 October.

Dr Brokenshire advised that a hospital referral was not
warranted based on Dr C's findings from the pelvic and abdominal
examination. Dr C's working assumption was that the IUD removal
would reduce Ms A's symptoms. I accept my expert's view that
Dr C made an appropriate decision in the circumstances. Dr C
told Ms A to return for reassessment if her pain and vomiting
worsened, and if she was unable to take fluids. However, Dr C
did not document her follow-up advice. Given that Ms A was
presenting for the third time with ongoing symptoms, Dr C should
have ensured that her notes provided a comprehensive picture of the
consultation.

In mitigation, my expert noted that the consultation occurred on
a Friday when doctors are generally busier and under greater
pressure. However, patients rely on their doctors to be attentive
to their concerns and to provide appropriate care regardless of the
day of the week on which they present.

Taking into account all of these factors, I conclude that Dr C
did not provide an appropriate standard of care on 1 October 2004
and breached Right 4(1) of the Code.

Documentation

Right 4(2) of the Code states that patients have the right to
have services that comply with relevant legal, professional,
ethical, and other relevant standards. This includes the
responsibility on providers to adequately document their
consultations, since accurate documentation and record-keeping form
a fundamental part of good quality care.

20 July 2004

Dr Brokenshire commented that Dr C's notes were barely of an
acceptable standard. I note that it was only when my Office
asked for clarification that Dr C confirmed that she did examine Ms
A during both consultations. However, she did not document
the findings of her abdominal examination and other baseline
observations, including Ms A's weight, pulse, temperature and blood
pressure. There is no record of any pregnancy test. Dr
C also omitted to document the risk factors that may have been
taken into account in her decision to prescribe the combined oral
contraceptive, or any discussion of the risks. Although Dr C
considered taking a vaginal and cervical swab at the next
consultation (when Ms A returned for her cervical smear and IUD
removal), this was not recorded in her notes.

1 October 2004

The documentation on 1 October 2004 was brief. Dr C
omitted the history of Ms A's gastrointestinal symptoms (vomiting
and diarrhoea), and gave the impression that her problem had
changed from dysmenorrhoea and menorrhagia to a more generalised
abdominal discomfort with associated diarrhoea and vomiting. Dr
Brokenshire noted that Dr C failed to record any baseline
observations (such as Ms A's temperature, pulse and blood
pressure), and the findings from her cervical, pelvic and abdominal
investigations. Given that Ms A was reluctant to have an
internal pelvic examination during the first consultation, it was
important to document that it had been carried out during this
consultation. Such records are useful for guiding other
doctors in follow-up care. My expert pointed out that there
was no comment in Dr C's notes of her impression of Ms A's general
wellness and appearance, and whether Ms A was still taking
antibiotics. In addition, Dr C did not record whether she had
sent Ms A's IUD for microbiological examination or her rationale
for not taking vaginal and cervical swabs.

The severity of Ms A's condition was not reflected in Dr C's
documentation. Nor was any follow-up plan documented.
This omission left future doctors unclear about any follow-up
required. Dr Brokenshire noted that another provider could be
left with the impression that the consultation on 1 October was for
a routine smear and removal of IUD, rather than "an acute and
chronic problem".

Where a patient receives care from two or more doctors, it is
particularly important that the documentation is as clear and
comprehensive as possible. Good records help ensure quality
and continuity of care, which is a patient's right, affirmed by
Right 4(5) of the Code. Dr Brokenshire pointed out that
doctors working in accident and medical settings need to be even
more vigilant in recording their patient's baseline observations
and their general impression of the patient's acuity and degree of
illness. Dr C's failure to record vital information relevant
to Ms A's history, care and treatment placed Ms A at risk of having
her care compromised when she consulted Dr D after-hours on two
occasions. In my view, Dr C's documentation of Ms A's
consultations on 20 July and 1 October 2004 did not comply with
professional standards and breached Right 4(2) of the Code.

Opinion: Breach - Dr D

Care and treatment

Ms A presented twice after-hours to Dr D: on Saturday evening 25
September 2004 with acute abdominal pain, and on Tuesday evening 5
October 2004 when she continued to be troubled by increased
abdominal pain.

Care and treatment on 25 September 2004

Dr Brokenshire had some reservations about Dr D's care and
treatment on 25 September 2004 but advised that it reached an
acceptable standard. Ms A was noted to be "pale, miserable,
sick and teary". However, aside from recording her body
temperature at 37.7oC (a reading indicative of fever[5]), there were no other baseline observations
to support Dr D's statement that she was "afebrile" and her
"observation normal". As Dr D was uncertain of Ms A's actual
diagnosis, chronicity and acuity, he should have ordered blood
tests even if the results were not immediately available for
after-hours consultations. By not investigating further, Dr D
gave the impression that Ms A's degree of illness was not
acute. While Dr D responded appropriately by conducting an
abdominal examination, Dr Brokenshire was uncertain from Dr D's
non-standard notes whether the examination was of an acceptable
standard. I comment on Dr D's documentation below.

Given that Ms A was of reproductive age, a rectal and full
pelvic examination should also have been offered. Ms A's refusal to
have a pelvic examination (by pushing away Dr D's hand) suggests
that she was in considerable pain. It is not clear that Ms A
had understood the importance of such an investigation or the need
for co-operation on her part. It is impossible to tell from
Dr D's notes what information he had given Ms A about the pelvic
examination. It would have been prudent for him to record
that she refused such an investigation, despite having been advised
of its importance. Ideally, Dr D would have taken pelvic
swabs. The absence of a pelvic examination meant that Dr D had to
make an educated guess as to Ms A's possible pathology.

Dr D was aware that the removal of Ms A's IUD was overdue, and
that she had an abnormal vaginal discharge. While it would
have been preferable for Dr D to remove Ms A's IUD and take vaginal
and cervical swabs during this consultation, it was reasonable for
him not to do so, and to document his advice that Ms A would see
her regular GP, Dr C, during the coming week.

To cover the likelihood of PID, Dr D prescribed metronidazole
and Augmentin. Dr D advised Ms A to admit herself to hospital
overnight if she became more unwell. Dr Brokenshire
considered Dr D's follow-up arrangements appropriate although Dr
D's notes do not indicate whether clear advice was given to Ms
A.

Overall, Dr D's care and treatment on 25 September 2004 was
satisfactory and did not breach Right 4(1) of the Code. I
agree with Dr Brokenshire's view that this consultation was
complicated given Ms A'S issues and symptoms, and late
presentation.

Care and treatment on 5 October 2004

Dr Brokenshire advised that the care Dr D provided on 5 October
2004 did not reach an acceptable standard. Although this was
Ms A's fourth visit to the medical centre, and second consultation
with Dr D, he was unable to make a firm diagnosis. Dr D did not
give sufficient consideration to Ms A's protracted medical history
or to the acuity of her presenting illness. Ms A looked "sore and
miserable" and was re-presenting with ongoing acute symptoms.
Rectal and pelvic examinations were not performed, nor a pregnancy
test. My expert advised that Dr D should have
considered abdominal imaging (ultrasound or CT scan), ordering
urgent blood tests, and a specialist referral with the view to
possible laparoscopy or laparotomy. Although the outcome may
not have differed, it would have been prudent for Dr D to initiate
further investigations.

Dr D noted that Ms A was "sore all over", "pushed his hand away
[during the abdominal examination]", and was also sore in her upper
right abdominal area. Her bowel sounds were normal.
However, my expert was unable to conclude whether the abdominal
examination was adequate because Dr D did not document whether Ms A
had any abdominal masses or tenderness. In addition, Dr
Brokenshire advised that Dr D should have investigated the bowel
sounds further or referred Ms A to hospital. Normal bowel
sounds in a person with ongoing acute symptoms are often indicative
of acute pathology and possible peritoneal inflammation.

Dr Brokenshire commented that Dr D should have expedited Ms A's
referral to hospital. It was inappropriate for him to send
her home that evening with the follow-up advice that she either
admit herself to hospital, or return to the medical centre if her
condition did not improve. His decision was imprudent given
that he had made a probable diagnosis of pelvic inflammatory
disease 10 days earlier, and was aware that Ms A had not completed
her course of antibiotics. In addition, Dr D should have
given greater consideration to Ms A'S unhappiness at being sent
home. His decision not to admit to hospital may have been
based on past experience of long delays at the hospital's emergency
department. In fact, Ms A did not experience any significant delay
in accessing hospital care later that evening when her condition
had not improved.

In summary, in a number of respects, the care and treatment Dr D
provided on 5 October was not of an appropriate standard, and he
therefore breached Right 4(1) of the Code.

Documentation

Dr D's notes are generally legible and relatively
comprehensive. Dr Brokenshire commented that his
documentation is a reasonable record of the care he provided,
despite containing some non-standard annotation in relation to Ms
A's abdominal signs. However, while Dr D's notes of 25
September were adequate, his records of 5 October fell short of the
standard expected of a doctor working in an accident and medical
setting. Dr D failed to document any abdominal masses,
rebound, tenderness and enlargement of organs that may have been
observed during the examination. Consequently, my expert was
unable to ascertain whether Dr D's abdominal examination was
adequate, and commented that it "left the reader uncertain as to
[his] exact findings".

I accept Dr Brokenshire's advice. In my opinion, Dr D
breached Right 4(2) of the Code in relation to his record-keeping
on 5 October 2004.

Opinion: No Breach - The Medical Centre

Complaint

Ms A complained about the length of time she waited to be
assessed after arriving at the medical centre on 5 October
2004.

Ms A's complaint raises two issues about the medical centre's
triage system. The first is whether Ms A was adequately
triaged by relevant staff on 5 October 2004 (a care and treatment
issue involving Right 4(1) of the Code), and the second is whether
the medical centre had a triage system in place that complies with
the relevant standards for Accident and Medical clinics (a
standards issue involving Right 4(2) of the Code).

Care and treatment

My expert advised that Ms A was adequately and appropriately
triaged on 5 October 2004. She was assessed by a registered
nurse, Ms E, within seven minutes of her arrival at the medical
centre, which was an acceptable time frame. During the triage
assessment, Ms E recorded Ms A's blood pressure, pulse, temperature
and observed behavioural indicators of her pain. My expert
commented that the important aspects of triage (such as baseline
observations, brief history of the complaint, patient's general
appearance, distress and perceived unwellness) were
completed. In addition, Ms E checked Ms A regularly while she
waited to see a doctor, and acted promptly when she complained of
worsening pain. Although it was appropriate to triage Ms A as
category 4, Dr Brokenshire advised that she could also have fitted
into triage category 3 based on her presentation and baseline
observations.

It is clear that Ms A experienced pain and discomfort when she
presented on 5 October 2004. Despite her symptoms and acute
discomfort, she was appropriately assessed and triaged that
evening. Therefore, in my opinion, the medical centre did not
breach Right 4(1) of the Code.

Standards

The medical centre is an ACC-endorsed level 2 Accident and
Medical Clinic. As such, it is required to comply with the New
Zealand Standards for Accident and Medical Clinics NZS 8151:2004
(Standards) in place at the time Ms A received care.[6] Triage is defined in the Standards
as:

"… an initial assessment of the severity of the consumer's
condition, in order to determine priority of treatment".

Dr Brokenshire advised that the medical centre's triage system
complies with the Standards. The medical centre has a
written policy for triaging patients that is well understood and
adhered to by nursing and medical staff. My expert commented
that the triage codes adopted by the medical centre fit the
Australasian College for Emergency Medicine's triage
scale.

Accordingly, I conclude that the medical centre did not breach
Right 4(2) of the Code in relation to the care they provided Ms
A.

Dr Brokenshire commented on the medical centre's paper-based
triage system in place at the time Ms A received care. He
indicated that there is room for improvement in the documentation
of assessments and baseline observations, which form the basis of
the triage category assigned to a patient. My expert
suggested incorporating into the triage form a section for
recording the nurse's/doctor's observations, a brief history of the
presenting complaint(s), examinations carried out, and
nurse-initiated investigations and interventions (such as the
administration of pain relief according to standing orders).
The medical centre advised that in 2005, a computerised system for
triage was implemented, which enables all triage assessments to be
documented electronically and audits to be conducted.

This case also highlights the importance of a patient recall
system. Although the medical centre had a recall system in
place when Ms A consulted Dr C in July 2004, it was not
computerised to record missed appointments. Since then,
changes have been introduced allowing missed appointments,
cancellations and rescheduled appointments to be recorded online in
the patient's notes, and audits to be conducted where staff members
cancel appointments. These changes will encourage timely
follow-up by relevant staff when patients miss appointments and
fail to re-present within the advised timeframe.

Vicarious liability

In addition to any direct liability for a breach of the Code,
employers may be vicariously liable under section 72(2) of the
Health and Disability Commissioner Act 1994 for any breach of the
Code by an employee. Under section 72(5) of the Act, it is a
defence for an employing authority to prove that it took such steps
as were reasonably practicable to prevent the act or omission
leading to an employee's breach of the Code.

Both Dr C and Dr D were employed by the medical centre at the
time of the events in question. Dr C provided inadequate care
and treatment on 1 October 2004 and breached Right 4(1) of the
Code. Her standard of documentation fell short of the
standard expected of a general practitioner working in an accident
and medical setting, and breached Right 4(2) of the Code.
Similarly, Dr D's care and treatment on 5 October 2004 was
inadequate and breached Right 4(1) of the Code, and his
record-keeping for that consultation was deficient, breaching Right
4(2) of the Code.

I am satisfied that Dr C's and Dr D's omissions reflected
individual clinical judgement. Accordingly, the medical
centre is not vicariously liable for their breaches of the
Code.

Actions taken

Drs C and D

In response to my provisional opinion, Dr C and Dr D each
provided a written apology for their breach of Rights 4(1) and 4(2)
of the Code, and confirmed that they have reviewed their
practice.

The Medical Centre

The general manager advised that in 2005 improvements were
implemented to the medical centre's triage system and patient
recall system. Both systems are now computerised enabling a
greater amount of information to be recorded and audited
electronically.

Follow-up actions

A copy of this report will be sent to the Medical Council of
New Zealand and the Royal New Zealand College of General
Practitioners.

A copy of my final report, with details identifying the parties
removed, will be sent to the New Zealand Accident and Medical
Practitioners Association, and placed on the Health and Disability
Commissioner website, www.hdc.org.nz, for educational
purposes.

[5] The normal body temperature is
between 36oC and 37oC. A person has
fever when the body temperature rises above
37.2oC.

[6] Since 1998, Accident and Medical
Clinics have had the option of seeking ACC accreditation. In
the accreditation process, clinics are audited against a written
Standard, administered by Standards New Zealand. The Standard
addresses a number of areas fundamental to good Accident and
Medical Practice, including triage systems.

[7] Registered Nurse Ms E, who completed
the form, advised (via her lawyer) that the form is not
double-sided, despite "PTO" appearing on the bottom right-hand
corner.